Analysis Toxic Products of Combustion MDF has been determined to be a product not dangerous to transport and is not considered dangerous goods. The manufacturer does not have to provide the carrier with a material safety data sheet. Like other non-dangerous goods, however, when this combustible solid burns, it releases toxic gases. To inspect the cargo before the second response, the responders took the precaution of wearing self-contained breathing apparatus. The responders were not aware that hydrogen cyanide is given off when MDF burns. After the second intervention, the responders chose to use sensors to monitor the cargo hold. The IMO Dangerous Goods Code does not list, nor was it intended to list, products not hazardous to transport which, like most materials, give off toxic gases when burning. Extinguishing the Fire A burning smell was the first sign of a fire in the cargo. The first response was fast because both the stevedores and the crew members advised the resource persons. Good seamanship was observed in sounding the general alarm before fighting what, at first, appeared to be a minor fire. As set out in the MDF material safety data sheet, it is recommended to extinguish fires fed by wood, cardboard, and plastic by lowering the temperature of the fire area with water. Foam and dry chemical may also be used as smothering agents.5 As the scope of the fire was unknown, it was decided that extinguishers be used initially. Although the extinguishers were charged with dry chemical powder for various classes of fire, dry chemical powder has the property of smothering combustible solids. The seat of the fire was between two tiers of bundles; there was, therefore, no direct access. It was probably impossible to spread dry chemical powder over the whole surface of the fire area to smother the flames. The cardboard and polyethylene were flammable substances and, being exposed to the open air and heat in the space between the bundles, they were subject to rapid oxidation. Extinguishers have a limited discharge capacity, and they did not stifle the oxidation. The flames then spread between the bundles. Hoses with jet nozzle were used, but only approximately 10 percent of the water can absorb the heat of the fire. For this method to be effective and reduce the heat, the jet of water has to be directed right onto the source of the flames. Access to the centres of the fire was still restricted, and the fire probably spread to the point where it was impossible to cover the flames with two jet nozzles. A spray nozzle would have sprayed the water in a mist, which would have decreased the amount of oxygen sufficiently to prevent combustion from continuing. Unable to control the fire, the crew decided to isolate the cargo by closing the hatches and ventilation shafts, and injecting CO2, which is the safest and most effective extinguishing agent for hold fires. Water is less effective, as it can destabilize the vessel and damage cargo. CO2 acts as a blanketing and oxygen-diluting agent; as it is slow-acting, the user has to be patient. However, the hold was opened again the next morning. The physical and chemical action of the CO2 on the cargo and the ambient air lasted only about 19hours. This length of time proved insufficient to cool and smother the blazes. When the cargo was exposed to the open air, the centres of fire were exposed to a sufficient amount of air to kindle the fire. As the space between the bundles was hard to get at, foam was a wise choice as an extinguishing agent for the second response because it can be dispersed in such open spaces and cover the whole cargo. By covering the fuel, the foam isolates it from oxygen. In this instance, the firefighters may not have completely covered all of the fire areas when they exhausted the supply of foam, since the fire was not brought under control at that time. The responders then used fire hoses with spray nozzles. The water, however, dispersed the foam and, as the fire could still not be brought under control, the hold was closed again. The slow but effective action of CO2 over more than five days stifled the blazes. Observers of the fire agree that the first orange flames were noticed in the second bay from the aft bulkhead between the second and third tiers from the top. A centre of fire was found there. The second centre of fire was under the first centre of fire, but near the tank top. The second centre of fire near the tank top and the third centre of fire in the third bay were probably the result of secondary fires. The whitish-coloured smoke was probably actually light grey, and the subsequent black smoke was probably a dark-brown colour. These colours of smoke and flame are associated with burning wood. Water and air can sometimes generate a chemical reaction with MDF, but the polyethylene film packaging made the MDF impervious to the elements, and no loading had been done on rainy days. Combustion may result in chemical interaction between two or more substances. Medium-density wood fibre, cardboard, and polyethylene film are substances not at all likely to react violently together. The cargoes on the vessel's previous voyages reportedly did not leave any hydrocarbon deposits, and the tank top had been swept satisfactorily. The probability of a chemical reaction having initiated combustion is small. Had this been the case, the flames would have been discovered among the first tiers at the bottom of the hold. The electrical equipment on board the vessel is affected by potentially corrosive salt sea air or potentially damaging ship vibrations. In contact with the steel hull, the electrical wiring may cause short-circuits, overheating or arcing capable of setting fire to nearby flammable substances. The fact that the 'tween-deck hatch-cover motors were not operated reduced the possibility of arcing over the bundles. A spark could have ignited a gas, but there was no explosion. Moreover, as the first centre of fire was noticed under the second tier of bundles from the top, the possibility that a spark worked its way between the bundles is small. The state of the electrical wiring after the fire was the result of fire damage to the equipment. For a combustible solid to ignite, it has to pass into the gaseous state. In a fire, this transformation usually occurs as a result of the initial heat. The fire was not the result of improper stowage. There was no friction-inducing shifting of the bundles producing a heat source. If a heat source in the engine-room had heated the hold aft bulkhead, heat transfer by radiation would have caused a fire in way of the first bay adjacent to that bulkhead. However, no centre of fire was discovered in that bay. Some materials not usually subject to spontaneous combustion may ignite of their own accord under certain conditions. Wood is one of them, but the cargo concerned here was a wood product. MDF is a very dense material, and it had been manufactured into panels. Solid materials take hours or even days to burn. On the day of the fire, the crew and the stevedores were present throughout the day around the cargo, and the burning smell and smoke were detected quickly. The beginning of combustion did not go unnoticed. Some factors conducive to spontaneous combustion are poor ventilation and a high ambient temperature as in an enclosed space. In this instance, the hold was wide open and hence fully ventilated, and the temperature of the ambient air was that of a temperate Canadian fall. Statistics do not show any case of spontaneous combustion. The elements and prevailing conditions were not conducive to spontaneous combustion. An inspection of holds Nos3 and5 revealed several smoker-related items even though there were orders prohibiting smoking, and offenders were subject to penalties. This indicates that some people smoked in the holds. The information found suggests that a smoker-related item, probably a cigarette butt, was thrown in way of the first centre of fire while preparations were under way to stow the third bay. This would have occurred after lunch, around 1330. As the ignition point of a cigarette butt is higher than that of polyethylene, cardboard, and fibreboard, in the half hour before the discovery of the fire, the butt would have burned and then set fire to the cardboard, the polyethylene film, and eventually the MDF. A butt some 20mm long would have burned for about 4or 5minutes, which is long enough to transfer heat by conduction to the cardboard and polyethylene film. The space between the bundles was conducive to combustion, the materials were all combustible, there was enough air, and the area was sheltered from the wind. Role of the Supervisory Staff MDF is an unregulated product and is not classified as dangerous goods. It therefore does not require any special handling precautions. The crew paid attention to stability and stowage as for all general cargo, but the crew members and stevedores paid no special attention to fire hazards. Everyone has a role to play in accident prevention. Supervisors are responsible for enforcing fire safety policy. Creating awareness among stevedores and crew members about cigarette-smoking related hazards can certainly improve safety in the workplace, especially safety in enclosed spaces. Supreme Authority on Board The master of a foreign vessel is the supreme authority on board, but must comply with Canadian legislation. A foreign merchant vessel is not considered sovereign territory and, accordingly, an official of the Government of Canada can board a vessel to conduct departmental duties. To avoid delays in decision making, emergency plans should specify to the main responders the areas for which they have primary responsibility within a unified command structure. It is probable that a cigarette end was discarded in the space between the bundles of MDF where orange flames were seen in what was later determined to be the seat of the primary fire. The fire was probably started between the bundles of MDF by a lit cigarette end transferring heat by conduction to the cardboard and polyethylene film which wrapped the MDF. The other two centres of fire discovered were probably the result of secondary fires. The extinguishers discharged by the crew in the first response had a limited discharge capacity and did not stifle the flames which were spreading amongst the bundles. The jet nozzles used by the crew in the first response proved ineffective because the water jet could not be played directly onto the flames to reduce the heat. Although the hold was closed and carbon dioxide gas (CO2) released, the hold was re-opened before the CO2 had time to smother the fire. Further attempts by the crew and professional firefighters to extinguish the fire with a limited supply of foam and by water spray were unsuccessful, and the hold was resealed. A further supply of CO2 was released into the hold and its slow but efficient action stifled the fire after five days.Findings as to Causes and Contributing Factors It is probable that a cigarette end was discarded in the space between the bundles of MDF where orange flames were seen in what was later determined to be the seat of the primary fire. The fire was probably started between the bundles of MDF by a lit cigarette end transferring heat by conduction to the cardboard and polyethylene film which wrapped the MDF. The other two centres of fire discovered were probably the result of secondary fires. The extinguishers discharged by the crew in the first response had a limited discharge capacity and did not stifle the flames which were spreading amongst the bundles. The jet nozzles used by the crew in the first response proved ineffective because the water jet could not be played directly onto the flames to reduce the heat. Although the hold was closed and carbon dioxide gas (CO2) released, the hold was re-opened before the CO2 had time to smother the fire. Further attempts by the crew and professional firefighters to extinguish the fire with a limited supply of foam and by water spray were unsuccessful, and the hold was resealed. A further supply of CO2 was released into the hold and its slow but efficient action stifled the fire after five days. Smoking was prohibited in the work area but effective enforcement of this rule was lacking. MDF has been determined to be a product not hazardous to transport. It is not listed as dangerous goods in neither the IMO Dangerous Goods Code nor Canadian Dangerous Goods Shipping Regulations. The manufacturer did not have to provide the carrier with a material safety data sheet, and the crew and the firefighters learned of the MDF material safety data sheet only after the second response. To date, policy or programs intended by TC to promote the training of firefighters in municipalities with public ports have had limited effect.Findings as to risk Smoking was prohibited in the work area but effective enforcement of this rule was lacking. MDF has been determined to be a product not hazardous to transport. It is not listed as dangerous goods in neither the IMO Dangerous Goods Code nor Canadian Dangerous Goods Shipping Regulations. The manufacturer did not have to provide the carrier with a material safety data sheet, and the crew and the firefighters learned of the MDF material safety data sheet only after the second response. To date, policy or programs intended by TC to promote the training of firefighters in municipalities with public ports have had limited effect. Safety Action Action Taken Following the accident, Port Saguenay purchased a portable fire pump to offset the inadequate flow provided by the Ville de La Baie water supply system. In February 1999, the municipality of Ville de La Baie revamped its municipal emergency plan on the model of the Emergency Preparedness Canada publication. In the event of a response on board a ship, the plan states that a coordination team - consisting of the master, a representative of the agency concerned, and the head of the fire department - will draw up a joint response plan. The plan states that, legally in Canada, in a marine occurrence the concerted actions of these three responders have the authority on board a ship.